March 01, 2018 Curb your cravings

[00:00:00] Now we'd like to welcome our speaker Sarah Coley and thank her for joining us today. But before turning it over to Sarah I'd like to give you a brief introduction. Sarah Coley was born and raised in Winnipeg, Manitoba. She obtained her degree in nutritional science from the University of Manitoba and completed her dietetic internship in Manitoba. Sarah is extremely passionate about diabetes. She's worked full time in diabetes for 13 years, volunteers for various diabetes events and as the chair of the professional section for the Manitoba chapter. For more information on Sarah please read the speaker bio section and that is located to the left of your screen. So without further ado I present to you Sarah Coley.  

[00:00:48] Thanks Vera. Hi everyone. My name is Sarah Coley. Thanks for joining in today. I'm presenting from lovely sunny Winnipeg here. So I'm very excited to talk to you today about carb counting. It's one of those: Oh no, do you know how to carb count. It is a hot topic always in diabetes. And I'm going to try and make it a little bit easier for you to do today. I have no conflicts of interest to declare.  

[00:01:26] OK so where are we going with this presentation. Step number one is to be able to identify which foods affect your blood sugar, so which foods have carbohydrates. We're going to look at our carb counting skills. So we're going to start with the basics, which is more eyeballing or estimation. We're going to look a little bit more advanced into labels. We're going to look at measuring foods and using food scales. We're going to talk about different resources that are available.  

[00:02:05] All right. So first off what are carbohydrates. I always say carbohydrates or carbs are a fancy word for foods that raise our blood sugar. Carbohydrates break down into sugar, which is glucose, and our brain must use glucose or sugar for our energy. Why should we count carbs? So carbohydrates have the most impact on blood sugar levels. If we count carbohydrates we can possibly have less glucose excursions so less highs and less lows. We'll feel better when our blood sugars are more stable. We have more flexibility in meals and snacks which can kind of see there's no off limit foods. We can include all foods and overall we'll have better blood sugars and a better A1C.  

[00:03:09] All right so let's take a couple minutes here. If we want to look at this slide if we start at the top left there is a salad there. I want you to kind of take a couple minutes and just write down if these foods contain carbohydrate or not. So number one would be salad. And I'll just give you a hint that that's just vegetables and vinegar dressing no croutons. The second one is chili. If we go up, number three would be black coffee. Four is bananas. And if we go to the bottom row now we've got a happy looking corn on the cob. We've got dancing milk and that would be cows milk and then this next one is actually oil. So we could just say olive oil for the purpose of this example. If we go down that's bacon and eggs. Up slightly is an avocado and then we've got a little mice carrying their block of cheese. So a couple of minutes there if you want to jot down to test your knowledge for identifying carbohydrate. OK so let's review for the first one is salad. So salad we mostly count as negligible. Most of the available carbohydrate is close to zero to five grams per cup. We usually don't count salad. If we go to the next picture, that's chili. So Chili we have some beans in tomato sauce that will have carbohydrate. And if we look at black coffee. So this is actually kind of a trick question. I'm sorry I had to throw this in here. So black coffee is counted as zero carb. However some of you could notice that in the morning if you're not eating and you have black coffee sometimes black coffee can make people's sugars go up and it has nothing to do with the carb. It's just a lot of caffeine for some people can cause that adrenaline response, so it causes that fight or flight syndrome and your body can release stored sugar. So this is just a side note but we would count coffee as black coffee a zero and we wouldn't take any insulin for extra coffee. But just so you know that this in some people can make their sugars go up. If we call the next picture we've got bananas. Bananas are a great source of carbohydrate and then the bottom we've got a happy looking corn on the cob. I think that's so cute. So yes corn on the cob is carbohydrate. And our cow’s milk is also carbohydrate. Some of the unsweetened almond milk will be zero. So it's just good to know which type of milk your consuming. Oil will be no carb. Bacon and eggs will be no carb as long as you're not using ketchup. Avocado will actually be no carb. So I have a lot of people ask about avocado. So very healthy. But a good source of energy, it is higher in fat. Then we've got a block of cheese. So cheese will not affect blood sugars either.  

[00:06:46] OK. Let's move on to our next slide. How do we count carbs. Well first off we looked at being able to identify carbs. So if you have a meal in front of you you've got to be able to discern what has carbohydrate and what doesn't. The next step is going to be knowing what fits into a carb serving. So we count carbs in either serving sizes or carb choices or grams of carbs. So if we look at one carb serving or one carb choice that is equivalent to 15 grams of carbohydrate which if you want to visualize that (I'm a very visual person) that's three sugar cubes or three teaspoons of sugar. Now the next step would be eyeballing. So this is at the very basic level of carb counting. And this is good enough. If you're just on oral agents, no agents or just like a background insulin. Eyeballing your carbohydrate so that you're at about a consistent amount every day for breakfast at a consistent amount every day for lunch and a consistent amount every day at supper will make those blood sugars a little more stable. We're going to talk a little bit more about eyeballing in a few minutes and we're going to look freely at more advanced type scales: so looking at labels, measuring, using food scales, and then again talking about the carb counting resources.  

[00:08:29] Also what are some advantages of eyeballing. Well eyeballing obviously takes less time and it's less calculations. You kind of look at the meal and you can be able to identify what is carb and what isn't. Like I said if you're not on a meal time insulin you're just on oral agents or metformin or nothing or a background insulin then this is ideal for you. The disadvantages are if you're not quite sure and one meal you'll have a lot of carb the sugars will be higher after that meal or if you have a meal and you thought it had carbs and it doesn't. Then your sugars can be a little bit lower. Eyeballing or estimation can be very inaccurate. We know that roughly research shows that we are overestimating the foods we eat by about 20 to 25 percent. And it's not ideal if you're on a bolus or meal time insulin. So if you're on a meal time and somebody would like you to match up the carbohydrate a little bit better. But this is where we would start.  

[00:09:39] So how do we do this. So step one. I always say we can use the plate method for estimation of carb counting. So if we look at our plate which I think most of us are familiar with; it's great it's awesome it's pretty straight forward. So we've got a plat. Half of the plate is vegetables and these are non sweet vegetables. So the sweet vegetables that I would kind of count would be your carrots, peas, turnips, squash and parsnips and beets as well so these sweeter vegetables at one cup, I would I would count them as 15 grams of carbs or 1 carb choice. But these vegetables that we're talking about as half a plate, would be more like your salad your broccoli or cauliflower. These sorts of vegetables. So if we look at our plate, half the plate as vegetables, that would be very negligible and carb or we would say zero for the basics of the basic. If we look to the next category bottom right. We've got a quarter plate of meat and alternatives. So if this is fish, chicken, pork, beef, eggs, we do not count any of those foods unless there is a breading, batter if there's ketchup, if there's barbecue sauce. Now some of the proteins such as peanut butter, lentils we would count those. So those ones are not counted as zero. So typically per tablespoon of peanut butter you're looking at five grams of carbohydrate and lentils depending on which one. But usually about one cup we count is 15 or a serving. So if we are at a half a plate of let's say salad and broccoli a quarter plate is our chicken breast or a pork chop. So far we would count to zero. The next quarter plate is starch so let's say we've got a potato there or corn there or pasta, roughly a quarter of the plate is about two servings of most starches. So that would be potato, a medium size potato, a full corn on the cob, or one cup of corn, one cup of pasta. But when we look at rice, about a cup of rice or a quarter of the plate it's three servings or 45 grams of carbs so if we're just eating that plate a quarter plate of let's say rice a quarter plate of chicken and a half a plate of vegetables that would be 45 grams of carbohydrate roughly or three servings. If this was half a plate of vegetables a quarter plate of protein and a baked potato that would be roughly 30 grams. Now if we add one cup of milk cows milk. So that would be we could use 0 percent 1 percent 2 percent or whole milk. These all have the same amount of carbohydrates it's the fat that's difference in the milk. If we add a small piece of fruit such as an apple that would be another serving or 15 grams of carbs. So this total meal with the plate milk and fruit with a baked potato let's say as an example would be an example of 60 grams of carbohydrate or four servings. Which is very balanced. It's a healthy amount of carbohydrate. If we had the quarter plate a rice you're looking probably closer to 75.  

[00:13:34] We're going to go on estimating carbohydrates using our hands, which is another great tool. You have your hands. Everywhere you go. So it's actually great at estimation. So if we look at the size of your fist. So if everyone wants to make a fist in front of me right now take a look at that fist. Roughly the size of a lady's fist. It's going to be about 30 grams of carbs or two servings for starch. So again about the size of a potato that big is going to be about 30 grams a cup of corn a cup of pasta, same thing. Now a cup or a fist of rice while be about three servings which is 45 grams of carbs. The size of a fruit, so if you make a little fist there and are looking, the size of an apple that big will be about 15 grams of carbs or one serving.  

[00:14:42] If you make two hands in front of you. That's the portion of vegetables and we say that's negligible or close to zero. The palm of your hand and the thickness of your little finger, so let's say the size of a chicken breast, we would count as zero. The fats so that you're kind of your tip of your thumb we would count to zero. And a serving of milk, I always say about the size of your fist, which is roughly about a cup or eight ounces, which is two hundred and fifty milliliters. All right. So let's just move on for a second.  

[00:15:23] Now that we've discussed basic carb counting and estimation using either your hands or a plate or both let's move on to a little bit more advanced. Now this is ideal if you're on a mealtime insulin and you want to match the meal time insulin to the amount of carbohydrate you're eating. This is very important for people that want variability in their meals, flexibility in their meals and meal times, and they want less peaks and valleys with their blood sugars. Now not everybody needs to know advanced carb counting but for the purposes of this presentation I'm going to go through it.  

[00:16:10] All right so if we look at a little bit beyond the basics very cleverly named. We've got this, which is available obviously through Diabetes Canada. So if we go through Beyond the Basics, I don't know if you guys have all had a chance to look at this great resource but I'll explain it briefly here. So we've got the legend in the top left corner. So if we look at we've got the full shaded top which is one cup then we've got the half cup, we've got the quarter cup, next column we've got the tablespoon teaspoon items to be measured after cooking, then we've got foods by weight which is one ounce. And then if you notice we've got the little green marked boxes, which are found, on the left hand side of the sheet. The kind of yellowy-orange found on the right. So the left the little green ticks would be the lower glycemic index, higher fiber, less processed, healthier choices. To the right the 'choose less often' would be the more processed, lower fiber, higher glycemic index choices. So these are not to be avoided entirely but to be consumed here and there. OK. Now how this whole system works is on the left hand of this entire paper are your carbohydrate containing foods. On the right hand side of the paper these are your non carbohydrate foods but we're going to highlight a few on that side. If we go back to the carbohydrate containing foods. Each box is considered one serving or one carb choice, which is 15 grams of available carb for absorption. So if we look at a few things so we could look at the second column there's corn so that symbol means half a cup of corn would be an example of 15 grams of carbohydrate or one carb choice. If we look on the choose less often side we've got 10 french-fries as an example of one carb choice or 15 grams of carbs. Now this doesn't mean you're stuck with eating half a cup of corn or 10 fries. Obviously if you want one cup of corn that would be two servings or a 30 grams of carbs. If you want 30 fries then that would be three servings or 45 grams of carbs. The next category would be fruits. So they give a bunch of different array of fruits here. Now those blank boxes are for foods that you or your patients want to put commonly eaten foods in those little boxes. So let's say I eat a certain type of bread and I want to make my little note in the grain and starch on how much my bread is. Maybe it's 20 grams or twenty five grams or so, that's just little boxes for commonly eaten foods. The next category is Milk and Alternatives. So we've got our chocolate milk, our cow’s milk and our yogurt. We've got the blank spots again for anything that you'd like to add. And then at the bottom we've got other choices. So this is putting popcorn, jellies, jams, honeys, all those sorts of choices. Now if we go to the other side of the sheet we've got the vegetables. So most vegetables we count as negligible. However each baby carrot, one baby carrot, is one gram of carbohydrates. So definitely when you're eating more at one sitting that can add up. So for eating 15 baby carrots that would be roughly 15 grams of carbs. Which is about a cup. Finally say carrots, peas, turnips, squash and beats, more than a cup I'd kind of caution and to count that as a serving. Our next category is protein or meat an alternative. So most proteins will not affect our blood sugar. So cheese, cottage cheese, eggs, different types of fish, pork, chicken, beef, wild meats. Unless there's a breading or a batter or you're having it with like ketchup or barbecue sauce. Tofu, no, but we would caution you with legumes or lentils so at a cup we would count them as one carbohydrate or 15 grams of carbs and peanut butter we usually don't count. But I I caution people because I do have some people that will, including myself, eat peanut butter with a spoon so that can add up. It's about five grams or a teaspoon of sugar per tablespoon so depending on how much peanut butter you like that can add up. But typically we would not count that as well as any of the fats we typically don't count. So avocado, bacon, butters, you know mayo, margarine, nuts and seeds, oil, salad dressings and again just a caution with nuts and seeds at a serving size. They won't affect sugar. I mean there's some fats and some protein in there but in larger portion so like a handful or a cup that will add up.  

[00:22:21] So again this is just moving through the different serving sizes. So starches. What is 15 grams of carbs? What is that? So this is just some examples there. I do like often I do add the corn on the cob to the Beyond the Basics because I find I eat a lot of corn on the cob and I know a lot of my patients eat corn on the cob. So full corn on the cob would be two servings, which would be 30 grams of carbohydrates.  

[00:22:58] And then just some different routes. So it's interesting to note. I always think this is a cool trick. So if you make a little fist this is really hard to explain. But if you look at the lengths of your knuckles so your index finger all the way down to your pinky those four knuckles the length of that in a banana is 15 grams of carbohydrate or one carb choice. So most bananas that I buy would be about two of those which would be two servings or 30 grams of carbs sometimes maybe even more. So that's a cool trick that I picked up along the way. The other interesting trick is so you see at the bottom of this slide we've got 15 small grapes. So 15 small grapes is 15 grams of carbs. One grape is one gram a carb one cherry is one gram a carb and one baby carrot is one gram. So we thought that was kind of interesting.  

[00:24:08] And lastly we've talked about milk so just looking at the different 15 gram carb servings. There are so many choices and variety nowadays. That's right. I think it's great for patients to know how to read labels, which we're going to get into right away.  

[00:24:28] All right. Labels. So labels in Canada are slightly different than labels in the States. But for this presentation we're going to talk about labels in Canada now. I mean most of us I think look at labels and I say if you're not an avid label reader when you go to the grocery store only look at three new labels. If you're going to look at every label for everything you buy you are going to go nuts. So just a couple labels each time a lot of times you can just even start looking in your pantry at home and just looking at stuff because this can be very overwhelming. So first off when you look at labels. When you look at a label you want to look at the serving size they're talking about and compare it to how much you're eating. So you know if you are eating. Oh I don't know as an example let's say crackers and the serving sizes for four crackers. Are you eating four crackers? Are you eating two crackers? Or are you eating 14 crackers? So that's obviously important. Label reading is easy to do if there's a label, so often foods that are fresh and healthy don't have labels. So if you think of going to the grocery store and you're buying a bunch of bananas and you're buying some apples and you're buying some fresh chicken and a lot of stuff doesn't have labels. So this is not great, if you're relying solely on labels for carb counting. Another little funny thing is cereals. So all cereals are portioned in a twenty-eight gram weight. So this is not carbohydrate. This is 28 grams of actual weight, so it could be different. So if you're having Cherrios, it's one in a quarter cup serving. If you're having Rice Krispies, it could be one and a half cups. If you're having Mini Wheats, it could be half a cup. So this is kind of confusing when they put the weight there so just make sure you know what it's talking about.  

[00:26:56] Sometimes if I was looking at the other day I was I had a small bag of (I don't really want to say) but I had a small bag of chips and the serving size was twenty eight grams but the bag was fifty six grams. So you assume that you're having the bag which is a serving but actually you would have to multiply by two in that scenario. So sometimes you gotta kind of watch.  

[00:27:24] OK so let's just do label reading. So I've got a label up here. So if we look at step one would be looking at the serving size, which is one bar. OK. So if you opened up this package and I know some granola bars they have two bars in one package. So that would just be a caution. But if you open up the package it's one bar. It weighs 80 grams. The outside package said 80 grams. You eat the whole thing then this is what you'd be getting. So I'm going to quickly explain here as we've got the total grams of carbohydrate, which are 20 and that's in a bold print underneath. We've got dietary fiber, which is three. We've got sugar, which is one. And we've got sugar alcohol, which is 12. Now of that 20 grams total, underneath indented we've got three of the 20 is fiber, one of the 20 is sugar, and 12 of the 20 is sugar alcohol. Now sugar alcohol is not a commonly found thing on foods but definitely I purposely picked this item to talk about it. Now the left over carbohydrate, which would be four grams, would be starch. So in Canada starch does not have to be on a food label. But as we know sugar and starch both contribute to your blood sugar levels. So when you're looking at this label you look at the total and you subtract the fiber. So that would be 17 grams of carb but you would also minus the sugar alcohol from this example as well. So it's just like fiber you subtract it. It does not count. So 20 minus three would be 17 because this product has sugar alcohol, which has to be labeled. Minus the other twelve. So 15, so that would leave you with a net of four. So hopefully everyone follows that OK. All right. Let's move on.  

[00:29:40] Also obviously foods come in different shapes and sizes. If they don't have a food label how much carb do they have? Well this is where the food scale and all your measuring cups comes into play so you can get extremely accurate. If you're using a food scale and you're using measuring tools such as measuring cups tablespoons teaspoons, etc., you can learn a ton from doing this even one meal a week or a couple meals a week. The cons are it's extremely time consuming and it's a pain. It's very tedious but honestly it does get a lot easier. And this is not fun for complicated recipes.  

[00:30:31] All right so I mean with food skills you can't really bring one with you. So if you were going out for dinner and there was no information on the carbohydrate content of things if you're going out to a friend's for dinner or you have a work event you're not really going to pull out your food scale or your measuring cups and figure stuff out. Now if you're using a food scale now for some of the cheaper scale, I bought one on Amazon for 10 bucks, it was free shipping so I bought one of the cheaper ones. Then you would need a food factor handout, which I'll kind of shows you. The more expensive scale, you're looking at about 60 bucks on Amazon, you'd put kind of your baked potato on it and you would kind of put in the code for baked potato and it would tell you how many grams of carbs you were eating. The scale I bought doesn't do that, so I would put on my baked potato and you would get 5 grams of carbs per ounce so let's say find a five ounce baked potato that would be twenty five grams of carb. What about recipes. Well there are apps that do this, which I'll touch on at the end. But if you wanted to do one by hand I will run through how to do this with you. So you would do this ingredient by ingredient. If I picked one of my favorite banana breads, just a typical banana bread recipe, makes eight servings or eight slices from the loaf. So if we've got half a cup of butter I want you guys all to jot down how many carbohydrates you think that has. Got one cup of white sugar. We've got four medium bananas. A half a cup of all purpose flour. A teaspoon of baking soda a half a teaspoon of salt and a half a teaspoon of vanilla. So if you just want to add up that quickly. Add up your butter your sugar, your bananas all of that together. And how much is the total loaf? And then per serving you had to go divide by eight. So let's see what we've got.  

[00:33:01] OK so let's see what we all got. So half a cup of butter with zero. A cup of white sugar would be two hundred grams of carbs with no fiber. The four medium bananas would be a net carb of 104. The flour is forty five. So if we add up all that together that would be three hundred and forty nine grams of carbs for the loaf. So per serving, if we cut it into eight pieces that would be almost forty five grams of carbs or three servings. Carb counting resources. So a lot of restaurants have their nutrition information available so you can look at it ahead of time on their website. Some restaurants and fast food places have it on site or you can use, there are several awesome apps and Web sites. So I use my fitness pal often. It does have the recipe analyzer on there for you. Spark people's good, Mynetdiary. So there are tons of different apps that you can track all of the information as you go. So I'm looking at the carbs and make sure you're subtracting the fiber from that. Now I challenge all of you to try honestly tracking what you're eating for a day for a meal for a week or so actually weighing or measuring every single food you eat and inputting that into an app or keeping track of it by hand and you're going to be shocked. Honestly.